Special Review
Stephen E. Rubesin, MD
Marc S. Levine, MD
Igor Laufer, MD
Hans Herlinger, MD
Index terms:
Barium enema examination, 75.1281,
75.1282
Colon, radiography, 75.1281,
75.1282
Review
Radiology 2000; 215:642650
1 From the Department of Radiology,
Hospital of the University of Pennsylva-
nia, MRI, Bldg 1, 3400 Spruce St,
Philadelphia, PA 19104. Received June
18, 1999; revision requested August
12; revision received August 27; ac-
cepted August 30. Address correspon-
dence to S.E.R. (e-mail: rubesin@oasis
.rad.upenn.edu).
S.E.R. and M.S.L. are consultants to
E-Z-Em.
r RSNA, 2000
642
Double-Contrast Barium
Enema Examination Technique1
This review article presents the principles for performing a safe, comfortable, and
accurate double-contrast barium enema examination. The procedure is a flexible
examination in which the fluoroscopist interacts with the patient, the controls of the
fluoroscope, and the image on the television monitor. During a double-contrast
examination, images of the colon are created by manipulating the patient, the
barium pool, and the amount of air insufflated into the rectum. Fluoroscopy is
essential for guiding the radiologist to obtain spot images with adequate technical
factors. The fluoroscopist analyzes the luminal contour, the barium-coated mucosal
surface en face, and the barium pool to detect abnormalities in the colon. With
careful technique, a high-quality examination can be performed in most patients.
The recent focus on colonic cancer screening has renewed interest in the double-contrast
barium enema examination and has stimulated the writing of this article as one of a
four-part series on colonic imaging. The purpose of this review article is to describe and
illustrate general concepts in the performance of a high-quality double-contrast barium
enema examination.
The double-contrast barium enema examination has existed in one form or another
since the 1920s and 1930s (15). The double-contrast barium enema examination
technique was still in its infancy in the 1940s and 1950s but improved dramatically in the
1960s and 1970s with improvements in preparation of the patient, enema tube tips, and
coating properties of high-density barium (69). Today, there are numerous textbook
descriptions of the barium enema examination technique (1018). As there are more ways
to perform a barium enema examination than there are radiologists, we will describe the
principles of performing a safe, comfortable, and accurate double-contrast barium enema
examination only as performed at the Hospital of the University of Pennsylvania (19). We
will provide the rationales for the components of our tailored double-contrast barium
enema examination.
PREPARATION FOR BARIUM ENEMA EXAMINATION
The patient must be prepared both physically and mentally to undergo a barium enema
examination. Both the radiologist and the patients physician take an active part in the
preparation of the patient. The radiologist provides simple, readable instructions for the
colonic preparation. The radiologist also provides a brief written description of the examina-
tion. The written description of the study and a verbal description of the examination by
the referring physician will help alleviate patient apprehension about undergoing a barium
enema examination.
Numerous physical preparations have been described and tested scientifically (2038).
The plethora of preparations reflect the inability to achieve a clean colon in all cases.
Success in colon cleansing is often a function of patient understanding and compliance
with the preparation, as well as of the patients own baseline colonic motility. Most
preparations are successful in young, healthy, mobile outpatients. Colons in patients with
colonic hypomotility, however, may be difficult to clean completely. This group includes
patients who are bedridden, patients with motility disorders such as diabetes or sclero-
derma, and patients taking opiates or drugs with anticholinergic side effects. In patients in
whom colonic hypomotility is suspected, a prolonged low-residue diet, a full 2-day
preparation, or cleansing enemas may be of value.
Most preparations include a low-residue diet for 13 days prior to the examination, a

a.
b.
Figure 1. Barium pool obscures polyp in
splenic flexure. (a) Spot radiograph obtained
with the patient in a right posterior oblique
position shows the splenic flexure. The barium
pool obscures the en face mucosal detail of the
descending limb of the splenic flexure. The
luminal contour is seen either as a continuous
white line (black arrow) or as a smooth edge of
the barium column (white arrow). (b) Spot
radiograph obtained with the patient in an
erect right posterior oblique position shows the
splenic flexure. A 7-mm polyp is manifested in
the shape of a bowler hat. The brim of the hat
(solid arrows) represents barium trapped be-
tween the base of the polyp and the adjacent
normal mucosa. The dome of the hat (open
arrow) represents the top of the polyp. The
polyp is pointed inward, toward the longitudi-
nal axis of the bowel.
Volume 215 Number 3
solution that keeps enteric contents semi-
fluid, and an orally administered agent
that stimulates colonic contraction. Pa-
tients must drink copious liquids (more
than 2.0 L) to minimize the dehydration
caused by the preparation. In some regi-
mens, a cleansing enema (colonic lavage)
is performed.
We use a 24-hour preparation that in-
cludes a low-residue diet, magnesium ci-
trate, bisacodyl tablets, and a bisacodyl
suppository. Other preparations may be
equally effective. However, we do not
recommend the use of large-volume
(4.0-L) isotonic lavage agents, such as
PEG-3350 and electrolytes for oral solu-
tion (GoLYTELY; Braintree Pharmaceuti-
cals, Braintree, Mass), as they leave excess
fluid in the colon and impair mucosal
coating in many patients (28,29).
The referring physician must prepare
the radiologist and the patient. The requi-
sition slip for the examination should
state the appropriate clinical history, sur-
gical history, and medications the patient
takes that have colonic side effects or may
cause colonic disease. The referring physi-
cian should state if a recent endoscopic
intervention has been performed, be-
cause there should be a 1-week interval
between barium enema examination and
performance of large-forceps biopsy
through a rigid sigmoidoscope, snare
polypectomy, or hot biopsy (39,40). These
endoscopic interventions may tear the
colonic mucosa and result in a small risk
of perforation if a barium enema examina-
tion is performed immediately after
the endoscopy. Performance of a small-
forceps biopsy through a flexible sig-
moidoscope or colonoscope does not pre-
clude performance of barium enema ex-
amination on the same day.
MATERIALS
Fluoroscope
In our practice, we use both digital and
conventional fluoroscopes. In the digital
units, the images can be obtained rapidly
and reviewed immediately, which short-
ens the procedure time by about 10 min-
utes (41). The use of digital radiography
also allows the technologists to spend all
of their time attending to the patient, not
to changing film cassettes. The digital
spot images are reviewed while the tech-
nologist obtains overhead radiographs,
which allows the radiologist to reimage
areas in question before the patient is
sent to the bathroom.
A washable pad covered by a sheet is
placed on the fluoroscopy tabletop. The
Double-Contrast Barium Enema Examination Technique 643
pad alleviates some patient discomfort, as
the bony protuberances of ribs and pelvis
rub against the fluoroscopy tabletop.
Insertion of the Enema Tube Tip
A digital examination of the anal canal
and distal rectum before insertion of the
enema tube tip is helpful (42). The digital
examination allows for evaluation of hem-
orrhoids, masses, or inflammatory condi-
tions that may make insertion of the
enema tube tip painful or even dangerous.
Digital examination also permits the radi-
ologist to assess sphincter tone, which
acts as a guide to whether the retention
balloon will need to be inflated. The
radiologist should wear a nonlatex glove,
as anaphylactic reactions to impurities in
latex have been reported (43).
A thin layer of lubricant is spread on
the enema tube tip. A lubricant contain-
ing lidocaine hydrochloride may allevi-
ate pain in patients with hemorrhoids or
inflammatory conditions. The enema tube
tip is pushed gently through the anal sphinc-
ter. If there is any difficulty with enema
tube tip insertion, a wide-bore, nonlatex,
Foley-type catheter may be used, because
it is softer and of a smaller diameter than
the standard Miller air tip (44).
Routine distention of the retention bal-
loon is not necessary, as use of the bal-
loon is associated with a small but finite
risk of rectal tear or abrasion and an
increased risk of hemorrhoidal bleeding
(45). Encouraging patients to retain the
air and barium is usually sufficient. Reten-
tion balloons are inflated only in patients
who are expelling air and barium from
the anal canal and only after a normal
distal rectum is demonstrated fluoroscopi-
cally.
Relative contraindications to the use of
the retention balloon include pelvic irra-
diation, various colitides, solitary rectal
ulcer syndrome, large distal rectal mass,
suspected rectovaginal fistula, and previ-
ous anal canal surgery. If inflated, the
balloon is distended not to coapt the distal
rectal walls but to act as a ball valve that
will be pulled back against the anal canal.
Agents for Colonic Hypotonia
We routinely use glucagon to induce
colonic hypotonia. One milligram of glu-
cagon is slowly injected intravenously
during a 1-minute period. The intrave-
nously administered glucagon works in 1
minute and lasts about 1020 minutes.
Intravenously administered glucagon de-
creases discomfort during barium enema

Figure 2. The mucosal surface en face.
Close-up view from a spot radiograph of the
sigmoid colon shows a 1.9-cm polypoid adeno-
carcinoma in a 68-year-old man with right
upper quadrant pain and subsequently proved
liver metastases. The mass is manifested as a
barium-etched hemispheric line (solid arrows)
surrounding tiny radiolucent tumor nodules
outlined by barium in the interstices of the
tumor; representative nodules are identified by
the open arrow. The normal mucosal surface is
featureless and gray.
examinations (4650). Glucagon is not
administered in patients with known in-
sulinoma, as its insulin-releasing effect could
cause hypoglycemia, nor is glucagon ad-
ministered in patients with known pheo-
chromocytoma, as it could elevate blood
pressure related to catecholamine release.
We compared the anticholinergic agent
hyoscyamine sulfate (Levsin) with gluca-
gon and found hyoscyamine sulfate less
satisfactory. In other countries, the anti-
cholinergic agent hyoscine N-butylbro-
mide (Buscopan) is available and is the
preferred agent to induce colonic hypoto-
nia (12,51). Hyoscine N-butylbromide, when
compared with glucagon, results in supe-
rior distention of the sigmoid colon (52).
Hyoscine N-butylbromide, however, is
currently unavailable in the United States.
Barium
A barium suspension designed for the
colon must perform several tasks. The
barium suspension must be of low enough
viscosity to scrub residual mucus and
feces into the barium pool. It must also be
644 Radiology June 2000
a.
Figure 3. Polyp demonstrated in barium pool. (a) Spot radiograph obtained with the patient in a
left-side-down position (left lateral view) shows the rectum early in the examination. At the edge
of the barium pool, there is a 7-mm lobulated radiolucent filling defect (arrow). The enema tube
tip obscures the distal rectum. (b) Spot radiograph obtained with the patient in a right-side-down
position (right lateral view) shows the rectum after enema tube tip removal. The polyp is not
depicted definitively. The distal rectum is no longer obscured by the enema tube tip. This polyp is
a tubular adenoma.
able to adsorb residual fluid and adhere to
the mucosal surface for enough time to
expose the radiographs. The barium sus-
pension must be radiopaque enough so
that a thin layer of barium will be visible
yet not so opaque that it obscures large
elevated lesions in the barium pool. We
currently use Polibar Plus (100% weight-
to-volume ratio; E-Z-Em, Westbury, NY),
which almost always gives good to excel-
lent mucosal coating, even in the pres-
ence of colonic fluid.
PRELIMINARY RADIOGRAPHY
OF THE ABDOMEN
In our department, scout radiographs are
obtained in all inpatients. Routine radiog-
raphy of the abdomen is not necessary
before all barium enema examinations,
especially in outpatients (53). Outpa-
tients fill out a questionnaire concerning
their clinical and surgical history and the
effectiveness of the previous nights prepa-
ration. Scout radiographs then are ob-
tained only in outpatients with a history
of gastrointestinal surgery or with a clini-
cal history suggesting obstruction, perfo-
ration, inflammatory bowel disease, fis-
tula, or abscess or if there are suspicions
of an ineffective colonic preparation.
BARIUM INSTILLATION
AND AIR INSUFFLATION
We traditionally have instilled barium
into the rectum while the patient lies in
b.
the prone position. In patients suspected
of having disease involving the anterior
wall of the rectum or rectosigmoid junc-
tion, the patient should be examined first
in the lateral position. Thus, in patients
suspected of having rectovaginal fistula,
endometriosis, or intraperitoneal metasta-
ses, we start barium instillation with the
patient in the left-side-down lateral posi-
tion. The enema tube is opened only partly,
as rapid distention of the rectum with
barium increases the urge to defecate.
The patient can be turned in various
positions to facilitate passage of the
barium through the colon. In general,
turning the patient to the left anterior
oblique or left-side-down position moves
barium into the proximal sigmoid colon,
descending colon, and splenic flexure.
Placing the patient in a slight Trendelen-
burg position aids passage of barium into
the splenic flexure. Once a full column of
barium reaches the apex of the splenic
flexure, turning the patient to the prone
position will move barium into the middle
of the transverse colon. During this time,
the radiologist uses fluoroscopy only
briefly but carefully analyzes colonic con-
tour and looks for filling defects in the
barium pool. If an abnormality is seen
while barium is filling the colon, a spot
radiograph is obtained.
A large enough volume of barium is
required to scrub and coat the colon. If
about one-third of the luminal diameter
of distended colon is filled with barium,
as demonstrated on radiographs obtained
with the patient in the decubitus posi-
Rubesin et al

a. b.
Figure 4. Colonic cancer not obvious on overhead images. (a) Spot radiograph obtained with the
patient in a right posterior oblique position shows a 3-cm coarsely lobulated polypoid mass
(arrows) on the anteromedial wall of the cecum and ascending colon, superior to and overlapping
the ileocecal valve (arrowhead). (b) Close-up view from an overhead radiograph of the colon
shows the edge of the ileocecal valve (arrow). The tumor is obscured by the barium pool. This is
the best image of the cecum from of a series of overhead images, including the decubitus views.
ity. The goal is to empty the rectal am-
pulla of barium, so that when air is insuf-
flated, bubbles will not be created in the
barium pool. The goal is not to clear the
entire rectosigmoid colon of barium. In
patients with a redundant sigmoid colon,
the patient may be turned to various
oblique positions, including an erect or
semierect position, in a greater effort to
clear barium from the sigmoid colon.
Room air is gently and intermittently
insufflated into the colon. Rapid succes-
sive squeezes on the insufflation bulb
results in discomfort and may incite recto-
sigmoid spasm. Many radiologists dis-
tend the colon with carbon dioxide rather
Figure 5. Spot radiograph obtained with the than room air, as carbon dioxide is rap-
patient in a near-erect position shows the idly resorbed from the colon, which results
middle of the transverse colon. The interhaus- in less discomfort during and after the exami-
tral folds are straight; a representative fold is nation. When we tried various carbon diox-
identified with an arrow. The haustral saccula-
ide insufflation systems, however, we did
tions are distended, but not overdistended and
flattened. not always achieve adequate colonic disten-
tion, especially late in the examination when
overhead radiographs were being obtained,
as carbon dioxide was absorbed and co-
tion, then enough barium has been in- lonic distention was diminished.
stilled to coat the colon (13). Too little
barium results in poor mucosal coating or
incomplete filling of the right side of the IMAGES
colon. Too much barium results in large
barium pools that may obscure lesions en Proper performance of the double-con-
face (Fig 1). trast examination requires an understand-
In general, we instill a column of barium ing of the components of the image to be
into the middle of the transverse colon interpreted as a guide to the image that
where it crosses the spine. Once the barium should be obtained. The size, shape, posi-
reaches the middle of the transverse colon, tion, and overall architecture of the colon
the enema bag is gently lowered to the are shown on overhead images, large
floor and the rectum is drained by grav- (14 3 14-inch) spot radiographs, or large-
Volume 215 Number 3 Double-Contrast Barium Enema Examination Technique 645
field digital images. Each colonic seg-
ment is viewed in detail on spot radio-
graphs or mid- to high-magnification
digital images. The luminal contour is
seen in profile either as a continuous
barium-etched white line or as a continu-
ous white edge of the barium pool (Fig
1a). With air contrast, the normal muco-
sal surface is seen en face as a smooth gray
surface. With some barium preparations,
or when the colon is slightly collapsed,
the innominate groove pattern is demon-
strated (54,55). Elevated lesions may be
manifested as filling defects in the barium
pool and alterations of its smooth edge.
The goal is to demonstrate each surface of
the colon, both with air contrast (Fig 2)
and with the barium pool (Fig 3), by
using the strengths of their properties to
analyze the colonic surface.
A double-contrast examination empha-
sizes the use of fluoroscopy to obtain spot
images. Before obtaining a spot image,
barium is allowed to flow across the mu-
cosal surface, the patient is turned to
eliminate most of the barium pool, and
then a spot image is obtained. Fluoro-
scopic guidance allows the radiologist to
assess and optimize the technical compo-
nents of luminal distention, bowel loop
projection, and mucosal coating. With
overhead radiographs obtained by the
technologist, there is little control over
precise positioning, luminal distention,
or mucosal coating. Therefore, the barium
enema examination that emphasizes spot
images is inherently superior to the exami-
nation that emphasizes overhead radio-
graphs (Fig 4).
Once barium is instilled and air is insuf-
flated, the radiologist must be flexible yet
compulsive. The order in which the spot
images are obtained is relatively unimpor-
tant and is flexible, as long as each loop of
colon has adequate barium coating and
distention and is demonstrated en face.
Compression is often helpful to splay apart
loops and analyze fluoroscopic findings.
In general, we obtain spot images in this
approximate order: sigmoid colon, rec-
tum, descending colon, splenic flexure,
transverse colon, hepatic flexure, ascend-
ing colon, and cecum.
The major technical pitfalls are obscur-
ing one loop with an overlap by another
loop and inability to fill the right side of
the colon. If barium refluxes through the
ileocecal valve before images of the sig-
moid colon are obtained, the sigmoid
colon may be obscured by barium in the
distal ileum. Therefore, at least two expo-
sures of the sigmoid colon are obtained
first to ensure that the sigmoid colon is
imaged before barium reaches the cecum.
 In general, the patient is turned to the
right-side-down position to move barium
into the hepatic flexure, then onto the
back to move barium into the proximal
hepatic flexure and ascending colon. To
move barium into the proximal ascend-
ing colon and cecum, the patient is turned
to a left-side-down or semierect position.
There is no such thing as air block, a
situation in which a colon distended by
air prevents further passage of barium
(56), because barium is much heavier
than air and will fill any dependent space.
If there is difficulty moving the barium
pool into the right side of the colon, it
usually means there is not a large enough
volume of barium.
When attempting to manipulate the
barium pool, the radiologist balances the
patients ability to turn on the fluoroscopy
table with the quality of the barium coat-
ing that is being achieved. In toto, the
patient is rolled 360 anywhere from one
to four times, usually in partial turns. If a a. b.
patient is elderly or feeble and has diffi- Figure 6. Value of the prone-angled view to display the sigmoid colon en face. (a) Spot
culty turning, the study should be con- radiograph of the rectum obtained with the patient in a left posterior oblique position shows a
verted to a single-contrast barium enema coarsely lobulated, barium-etched line (arrows) disrupting the normally smooth surface. (b) Overhead
radiograph of the pelvis with the tube angled 30 caudad and the patient in a prone position
examination. Most patients can accom- shows the rolled edges (arrows) of a long, centrally ulcerated, plaquelike lesion, which in this
plish two to three complete turns on position is seen in profile and is akin to the Carman meniscus sign. This is an adenocarcinoma at
the fluoroscopy table, which is sufficient the rectosigmoid junction.
for adequate colonic scrubbing and
coating.
The colon is viewed in various degrees
of luminal distention. The lumen should
be distended sufficiently so that the inter-
haustral folds are straight and oriented
perpendicular to the longitudinal axis of
the bowel. The rows of teniae coli are at
the edges of the haustral sacculations and
should be separated by about 23 cm (Fig
5). Colonic overdistention is painful, has
a small but finite risk of perforation, and
may efface plaquelike lesions. Conversely,
colonic underdistention may hide even
large lesions.
The enema tube tip may be removed
after an adequate amount of air and
barium has reached the right side of the
a. b.
colon. Early enema tube tip removal pro-
vides psychological and physical relief for Figure 7. Value of compression in the demonstration of overlapping loops. (a) Spot radiograph
the patient (57). Early enema tube tip obtained with the patient in a prone position shows overlap of the sigmoid colonic loops. (b) Spot
radiograph obtained with the patient in a prone position, with a compression balloon pushing on
removal is possible in young, mobile pa-
the anterior abdominal wall, shows separation of two of three sigmoid loops.
tients with good rectal tone. The enema
tube tip should be left in place in patients
who are expelling gas and in patients
who may need additional air to distend SPOT RADIOGRAPH POSITIONS moved, air-contrast views of the distal
the terminal ileum. We usually remove rectum are obtained with the patient in
the enema tube tip at the end of the The proximal rectum may be imaged the supine position. Another lateral view
fluoroscopic portion of the examination early, before enema tube tip removal, of the rectum is also obtained, but oppo-
(58), if not earlier, so we can obtain spot with the patient in both the prone and site to the one obtained previously, to
images of the distal rectum, an area that is lateral positions (Fig 3). With the patient place the barium pool opposite to that in
obscured by the enema tube tip and often in the prone position, the barium pool the first lateral rectal view (Fig 3).
difficult to depict at endoscopy, even in and enema tube tip obscure the distal The rectosigmoid junction may be ob-
retroflexion. rectum. After the enema tube tip is re- scured by overlapping sigmoid loops. A

646 Radiology June 2000 Rubesin et al

 a.

a. b.
Figure 8. Prone versus supine position for viewing the sigmoid colon and rectum. (a) Spot
radiograph obtained after enema tube tip removal with the patient in a supine position. The distal
rectum is seen in air contrast. The most caudal loop (arrow) of sigmoid colon is filled with barium.
(b) Spot radiograph obtained with the patient in a prone position, but the radiograph is printed in
the same anatomic position as a to allow direct comparison of images. Barium in the distal rectum
now obscures en face mucosal detail. The most caudal loop (arrow) of sigmoid colon is now seen
with air contrast. (a and b reprinted, with permission, from reference 19.)

lateral patient position is often best to
view this region. In addition, the over-
head view obtained with the tube angled
about 30 caudad and with the patient in
the prone position usually displays the
rectosigmoid junction (Fig 6). An angled
view also may be obtained with a remote-
control fluoroscope capable of tube angu-
lation.
The sigmoid colon is easy to image
when it is short and without diverticulo-
sis. However, the radiologist must use
every trick of the trade to depict a redun-
dant sigmoid colon involved by moder-
ate to severe diverticulosis. Radiologic
techniques to improve depiction of the
sigmoid colon include the use of compres-
sion (Fig 7), even with the patient in the
prone position, and placing the patient
in the prone (Fig 8), erect, or Trendelen-
burg position. The proximal sigmoid co-
lon often is best viewed with the patient
in the prone or left posterior oblique posi-
tion (Fig 9a); the distal sigmoid colon
often is best displayed with the patient in
the supine or right posterior oblique posi-
tion (Fig 9b). The most caudal loop of
sigmoid colon often is best seen with air
contrast with the patient in the prone
position (Fig 8).
Views obtained with the patient erect
are helpful for removing the barium pool.
Extensive use of images obtained with
the patient erect may obviate the use of
overhead images obtained with the pa-
tient in the decubitus position (59), espe-
cially in fluoroscopy rooms in which
cross-table views cannot be obtained.
Views obtained with the patient erect
should not be confined to the hepatic
and splenic flexures but are also useful in
the middle of the transverse colon (Fig 5),
a tortuous sigmoid colon, the ascending
and descending colon, and even the rec-
tum.
The table is elevated slowly and is
stopped three to four times to allow the
patient to attain equilibrium. When us-
ing a conventional fluoroscope, the radi-
ologist places a hand on the patients
shoulder as a reassurance that he or she
will not fall. When the fluoroscopy table-
top is tilted to the erect position, the
radiologist must be wary of the patient
having a vasovagal reaction. If the patient
feels light-headed or faint, closes his or
her eyes, or stops communicating, the
radiologist should return the table toward
the horizontal and carefully evaluate the
patients clinical status.
The proximal and middle sections of
the descending colon often are viewed
best with air contrast with the patient in
the erect or prone position. The distal
descending colon often is viewed best
with the patient in the recumbent supine
or oblique position (Fig 9). The splenic
flexure is viewed best with the patient in
b.
Figure 9. Spot radiographs of the sigmoid
colon with the patient in (a) a left posterior
oblique position and (b) a steep right posterior
oblique position. Identical segments of the
sigmoid colon are identified by similar arrows.
Changing the position of the patient changes
the location of the barium pool and allows
depiction of different segments of bowel en
face.
an erect (Fig 10) or recumbent (Fig 11)
right posterior oblique position. Women
are instructed to elevate the left breast
manually from the radiation field to
decrease radiation exposure to the
breast and prevent the soft-tissue shadow
of the breast from overlying the splenic
flexure.
A spot image should be obtained for
every loop in the middle of the transverse
colon. Whereas views obtained with the
patient in the erect position are superb
for the upper two-thirds of the lumen (Fig
5), images obtained with the patient in
the supine position better depict the infe-
rior one-third. The hepatic flexure is im-
aged with the patient in the erect left
posterior oblique position (Fig 12). Some-
times the medial wall is demonstrated
best with the patient in the supine posi-

Volume 215 Number 3 Double-Contrast Barium Enema Examination Technique 647


Figure 10. Spot radiograph of the splenic
flexure with the patient in an erect right poste-
rior oblique position. Diverticula are filled with
barium (short arrows) and coated with barium
(long arrow).
Figure 13. Cross-table lateral overhead radio-
graph obtained with the patient in a left-side-
down decubitus position.
tion. Again, women are instructed to el-
evate the right breast manually from the
radiation field.
The most distal part of the ascending
colon often is viewed best with the pa-
tient in the erect left posterior oblique
position. The proximal ascending colon
648 Radiology June 2000
Figure 11. Spot radiograph of the splenic
flexure with the patient in a horizontal right
posterior oblique position. The contour of the
descending limb is sacculated. Subtle mucosal
ulceration is manifested as shallow barium-
filled ulcers surrounded by radiolucent halos
(arrows). One week prior to this examination,
this patient had acute rectal bleeding during an
airplane flight. Endoscopic biopsy results re-
vealed ischemic changes.
Figure 14. Cross-table lateral overhead radio-
graph obtained with the patient in a right-side-
down decubitus position.
often is viewed best with the patient in
the supine or Trendelenburg position.
Images of the cecum often are obtained
Figure 12. Spot radiograph of the hepatic
flexure obtained with the patient in an erect
left posterior oblique position. The right breast
is elevated manually out of the radiation field.
Figure 15. Cross-table lateral overhead radio-
graph of the rectum obtained with the patient
in a prone position.
by using compression. The lateral half of
the cecum may be viewed best with the
patient in the left posterior oblique posi-
tion; the medial half of the cecum may be
seen better with the patient in the right
posterior oblique position (Fig 4a). If there
is too much barium in the cecum, the
patient may be rolled to the right in the
Trendelenburg position, to move barium
into the ascending colon, then turned
back to the left while still in the Trendelen-
burg position. If this maneuver does not
work, excess barium may be removed from
the cecum by rolling a nimble patient
360 toward the right while keeping the
patient in a Trendelenburg position. The
cecum also should be viewed either fluo-
roscopically or on spot radiographs with
the patient in the prone position, while the
anterior wall is bathed in the barium pool.
Demonstration of the appendix, ileoce-
cal valve, or terminal ileum means the
Rubesin et al
right side of the colon has been depicted
completely. Filling of the appendix and
terminal ileum is helpful in patients with
right lower quadrant pain and diarrhea,
respectively. Appendiceal and terminal
ileum filling often best occur before the
cecum is fully distended with air. By using
manual compression, barium may be
pushed into the appendix or terminal
ileum, particularly with the patient in the
erect or left posterior oblique position.
Because the ileocecal valve usually is lo-
cated on the posterior and medial cecal
wall, placing the patient in the prone
position often will result in reflux of air
into the terminal ileum.
OVERHEAD RADIOGRAPHS
AND POSTEVACUATION IMAGES
Overhead images provide the big pic-
ture and help piece together the spot
images. Overhead images are inherently
inferior in projection and distention but
are superior in minimizing magnification.
Barium coating visible on the overhead
images may be superior if barium coating
at fluoroscopy was thin owing to a large
original amount of intraluminal fluid. The
added time between spot radiographs and
overhead images allows additional turn-
ing of the patient and colonic absorption
of intraluminal water, which improves coat-
ing in some patients. In other patients,
however, the late timing of overhead
images may lead to barium flocculation.
We believe that the most important
overhead radiographs are the images ob-
tained in projections that the radiologist
cannot obtain at fluoroscopy: the left-
(Fig 13) and right- (Fig 14) side-down
decubitus views and the prone-angled
view of the rectosigmoid junction (Fig
6b). We also obtain a view of the abdo-
men with the patient in the prone posi-
tion and a cross-table lateral view of the
rectum with the patient in the prone
position (Fig 15). Overhead images are
not obtained routinely with the patient
in the supine or oblique position, because
these positions already have been imaged
extensively on spot radiographs.
Postevacuation overhead images are not
obtained routinely. However, postevacua-
tion fluoroscopic images and spot radio-
graphs may be obtained to demonstrate
delayed barium filling of tracks in pa-
tients suspected of having diverticulitis
or fistula. If the appendix or terminal
ileum has not been filled with barium but
should be imaged for diagnostic reasons,
postevacuation fluoroscopy sometimes re-
veals filling of these structures.
Volume 215 Number 3
SUMMARY
The double-contrast barium enema ex-
amination has as much potential in de-
tecting early cancers and precursor le-
sions as a any radiologic examination,
including mammography (60). Perfor-
mance of a high-quality double-contrast
barium enema examination requires a
radiologist who aggressively manipulates
the patient and barium pool yet is respon-
sive to what is happening on the fluoros-
copy table and television monitor. This
requires a combination of compulsive
scientist and barium artist, ready to tailor
the examination to the clinical history,
patient, and fluoroscopic findings.
References
1. Fischer AW. Fru hdiagnose des Dickdarm-
krebses, insbesondere seine Differentialdi-
agnose gegen Tuberkulose mit Hilfe der
kombinierten Luft- und Bariumfu llung des
Dickdarms. Deutsch Ges f. innere Med
1923; 35:8687.
2. Weber HM. Method for roentgenologic
demonstration of polypoid lesions and
polyposis of the colon. Proc Staff Meeting
Mayo Clin 1930; 5:326327.
3. Stewart WH, Illick HER. Method of more
clearly visualizing lesions of the sigmoid.
AJR Am J Roentgenol 1932; 28:379384.
4. Gershon-Cohen J, Shay H. The colon as
studied by double-contrast enema. AJR
Am J Roentgenol 1932; 27:838846.
5. Stevenson CA. The development of the
colon examination. AJR Am J Roentgenol
1954; 71:385397.
6. Welin S. Results of the Malmo technique
of colon examination. JAMA 1967; 199:
369371.
7. Brown GR. A new approach to colon
preparation for barium enema: prelimi-
nary report. Univ Mich Med Bull 1969;
27:225230.
8. Miller RE. Examination of the colon. Curr
Probl Radiol 1975; 5:340.
9. Laufer I. The double-contrast enema:
myths and misconceptions. Gastrointest
Radiol 1976; 1:1931.
10. Laufer I. Double-contrast enema: techni-
cal aspects. In: Double-contrast gastroin-
testinal radiology with endoscopic corre-
lation. Philadelphia, Pa: Saunders, 1979;
495515.
11. Maruyama M. Techniques of radiologic
examination. In: Radiologic diagnosis of
polyps and carcinoma of the large bowel.
Tokyo, Japan: Igaku-Shoin, 1978; 318.
11a. Maruyama M. Techniques of double-
contrast radiography. In: Radiologic diag-
nosis of polyps and carcinoma of the large
bowel. Tokyo, Japan: Igaku-Shoin, 1978;
1932.
12. Bartam CI. Radiological techniques. In:
Radiology in inflammatory bowel disease.
New York, NY: Dekker, 1983; 89.
13. Jones B, Braver JM. Technical aspects. In:
Essentials of gastrointestinal radiology.
Philadelphia, Pa: Saunders, 1982; 1343.
14. Altaras J. Radiologic examination of the
colon. In: Radiologic atlas of the colon
and rectum. Baltimore, Md: Urban &
Schwarzenberg, 1984; 138.
Double-Contrast Barium Enema Examination Technique 649
15. Gelfand DW. Radiographic techniques.
In: Ott DJ, Wu WC, eds. Polypoid disease
of the colon. Baltimore, Md: Urban &
Schwarzenberg, 1986; 4361.
16. Kelvin FM, Gardiner R. Techniques of
imaging and intervention. In: Clinical
imaging of the colon and rectum. New
York, NY: Raven, 1987; 2769.
17. Laufer I. Barium studies: principles of
double-contrast diagnosis. In: Gore RM,
Levine MS, Laufer I, eds. Textbook of
gastrointestinal radiology. Philadelphia,
Pa: Saunders, 1994; 3849.
18. Cittadini G. The Genoa technique in ac-
tion. In: Double-contrast barium enema:
the Genoa approach. Milan, Italy:
Springer-Verlag Italia, 1998; 1927.
19. Rubesin SE, Levine MS. Principles of per-
forming a double-contrast barium enema.
Westbury, NY: E-Z-Em, 1998; 135.
20. Miller RE. The cleansing enema. Radiol-
ogy 1975; 117:483485.
21. Miller RE. The clean colon: whose respon-
sibility? (letter). AJR Am J Roentgenol
1978; 131:182183.
22. Dodds WJ, Scanlon GT, Shaw DK, et al. An
evaluation of colon cleansing regimens.
AJR Am J Roentgenol 1977; 128:5759.
23. Kendrick RGM, MacKenzie S, Beckly DE.
A comparison of four methods of bowel
preparation for barium enema. Clin Ra-
diol 1981; 32:9597.
24. De Lacey G, Benson M, Wilkins R, et al.
Routine colonic lavage is unnecessary for
double-contrast barium enemas in outpa-
tients. BMJ 1982; 284:10211022.
25. Fork FT, Ekberg O, Nilsson G, Rerup C,
Skinhoj A. Colon-cleansing regimens: a
clinical study in 1200 patients. Gastro-
intest Radiol 1982; 7:383389.
26. Lee JR, Hares MM, Keighley MRB. A ran-
domized trial to investigate X-Prep oral
mannitol, and colonic washout for
double-contrast barium enema. Clin Ra-
diol 1981; 32:591594.
27. Irwin JP, Peterson GH. Colon preparation
for the barium enema: a guide for the
radiologist. Gastrointest Radiol 1982;
7:7578.
28. Girard CM, Rugh KS, DiPalma JA, et al.
Comparison of GoLYTELY lavage with
standard diet/cathartic preparation for
double-contrast barium enema. AJR Am J
Roentgenol 1984; 142:11471149.
29. Davis GR, Smith HJ. Double-contrast ex-
amination of the colon after preparation
with GoLYTELY (balanced lavage solu-
tion). Gastrointest Radiol 1983; 8:173176.
30. Hellstro m M, Brolin I. Dietary fibers in
the preparation of the bowel for diagnos-
tic barium enema. Gastrointest Radiol
1987; 12:7678.
31. Tomlinson TL, DiPalma JA, Mangano FA.
Comparison of a new colon lavage solu-
tion (GoLYTELY-RSS) with standard prepa-
ration for air-contrast barium enema. AJR
Am J Roentgenol 1988; 151:947950.
32. Gelfand DW, Chen YM, Ott DJ. Colonic
cleansing for radiographic detection of
neoplasia: efficacy of the magnesium
citrate-castor oil-cleansing enema regime.
AJR Am J Roentgenol 1988; 151:705708.
33. Gelfand DW, Chen MYM, Ott DJ. Prepar-
ing the colon for the barium enema exami-
nation. Radiology 1991; 178:609613.
34. Hageman MJHH, Goei R. Cleansing en-
ema prior to double-contrast barium en-
ema examination: is it necessary? Radiol-
ogy 1993; 187:109112.
35. Swarbrick MJ, Collins MC, Moore DJ, et
al. A comparative trial of magnesium ci-
trate (Citramag) and Picolax for barium
enema bowel preparation. Clin Radiol
1994; 49:379381.
36. Lai AKH, Kwok PCH, Man SW, et al. A
blinded clinical trial comparing conven-
tional cleansing enema, Pico-salax and
GoLYTELY for barium enema bowel prepa-
ration. Clin Radiol 1996; 51:566569.
37. Chan CH, Diner WC, Fontenot E, et al.
Randomized single-blind clinical trial of
rapid colonic lavage solution (GoLYTELY)
vs standard preparation for barium en-
ema and colonoscopy. Gastrointest Ra-
diol 1985; 10:378382.
38. Cittadini G. A simple, innocuous and
effective method for cleansing the large
bowel without enemas. In: Cittadini G.
Double-contrast barium enema: the Genoa
approach. Milan, Italy: Springer-Verlag Ita-
lia, 1998; 6166.
39. Harned RK, Consigny PM, Cooper NB.
Barium enema examination following bi-
opsy of the rectum or colon. Radiology
1982; 145:1116.
40. Maglinte DDT, Strong RC, Strate RW, et al.
Barium enema after colorectal biopsies:
experimental data. AJR Am J Roentgenol
1982; 139:693697.
41. Levine MS, Laufer I. The gastrointestinal
tract: dos and donts of digital imaging.
Radiology 1998; 207:311316.
42. Stewart ET, Dodds WJ, Nelson JA. The
value of digital rectal examination before
barium enema. Radiology 1980; 137:567.
650 Radiology June 2000
43. Gelfand DW. Barium enemas, latex bal-
loons and anaphylactic reactions. AJR Am
J Roentgenol 1991; 156:12.
44. Miller RE. A new enema tip. Radiology
1969; 92:1492.
45. Dodds WJ, Stewart ET, Nelson JA. Rectal
balloon catheters and the barium enema
examination. Gastrointest Radiol 1989;
5:227234.
46. Miller RE, Chernish SM, Skucas J, et al.
Hypotonic colon examination with gluca-
gon. Radiology 1974; 113:555562.
47. Meeroff JC, Jorgens J, Isenberg JUI. The
effect of glucagon on barium enema ex-
amination. Radiology 1975; 115:57.
48. Kreel L. Pharmaco-radiology in barium
examinations with special reference to
glucagon. Br J Radiol 1975; 48:691703.
49. Skucas J. The use of antispasmodic drugs
during barium enema. AJR Am J Roent-
genol 1994; 162:13231325.
50. Lappas JC, Maglinte DDT, Chernish SM,
Hage JP, Kelvin FM. Discomfort during
double-contrast barium enema examina-
tion: a placebo-controlled double-blind
evaluation of the effect of glucagon and
diazepam. Radiology 1995; 197:9599.
51. Sardanelli F. Glucagon and the colon. In:
Cittadini G, ed. Double-contrast barium
enema: the Genoa approach. Milan, Italy:
Springer-Verlag Italia, 1998; 7581.
52. Goei R, Nix M, Kessels AH, Ten Tusscher
MP. Use of antispasmodic drugs in double-
contrast barium enema examination: glu-
cagon or Buscopan? Clin Radiol 1995;
50:553557.
53. Eisenberg RL, Hedgcock MW. Preliminary
radiograph for barium enema examina-
tion: is it necessary? AJR Am J Roentgenol
1981; 136:115116.
54. Matsuura K, Nakata H, Takeda N, Nakata
S, Shimoda Y. Innominate lines of the
colon. Radiology 1977; 123:581584.
55. Rubesin SE, Furth EE, Rose D, Levine MS,
Laufer I. The effects of distention of the
colon during air-contrast barium enema
on colonic morphology: anatomic correla-
tion. AJR Am J Roentgenol 1995; 164:
13871389.
56. Miller RE. Solution for the air block
problem during fluoroscopy. AJR Am J
Roentgenol 1979; 132:10201021.
57. Maglinte DDT, Miller RE, Chernish SM,
Lappas JC. Early rectal tube removal for
improved patient tolerance during double-
contrast barium enema examination. Ra-
diology 1985; 155:525526.
58. Kahn S, Rubesin SE, Levine MS, et al.
Polypoid lesions at the anorectal junc-
tion: barium enema findings. AJR Am J
Roentgenol 1993; 161:339342.
59. Gelfand DM, Ott DJ. Double-contrast ex-
amination of the colon without decubitus
films. AJR Am J Roentgenol 1997; 169:
15651567.
60. Rice RP. Lowering death rates from colorec-
tal cancer: challenge for the 1990s. Radiol-
ogy 1990; 176:297301.
Rubesin et al